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Moving from diagnosis to explanation
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Moving from diagnosis to explanation

The role of knowledge work in approaching patients with Medically Unexplained Symptoms.
Walking
© University of York/HYMS

In the previous step we introduced the case of Omar, who has presented with a sensation of something being intermittently stuck at the back of his throat. As pathological causes have been excluded, we are starting to look for other explanations for Omar’s symptoms. For example, could Omar be experiencing a stress-related swallowing problem1?

This would fall under the umbrella of Medically Unexplained Symptoms (MUS).

MUS can be defined as persistent bodily complaints for which adequate examination (including investigation) doesn’t reveal sufficient explanatory structural or other specified pathology.
MUS account for up to 45% of all GP consultations2. They can be a source of anxiety and stress for patients, fear and frustration for clinicians and place a huge burden on the NHS and wider economy.

So how should we approach patients with MUS?

Managing our own anxiety is important. In this age of complaints and litigation it is easy to fall into the trap of over-investigation, so having tools to support a shift from diagnosis to explanation is vital.
GPs are expert generalists and this whole-person centred approach is precisely what’s needed here. Taking problems seriously, helping someone to make sense of their illness and address potential triggers, focusing on managing the impact of their symptoms rather than applying a diagnostic label and providing continuity of care can all help3.
Are these techniques you considered using when we introduced the case of Omar?
Our relationships with patients are certainly important when helping people with MUS, but there’s an added dimension we need to consider. We need to recognise the key role knowledge work plays in helping us to reframe someone’s problems.

Knowledge work is key to approaching patients with MUS

The problem we face is that patients suffering from persistent illness don’t fit our traditional disease models. GPs need to draw on their scientific understanding of how bodies work and breakdown their past clinical experiences, wisdom and mindlines (guidelines in-the-head), in addition to a patients’ own ideas or ‘creative capacity’, to co-develop explanations for symptoms. Helping people to understand their symptoms can assist them to work collectively with their clinician to explore different ways of managing their problem.
Through this collaborative work with patients, GPs can shift the emphasis from seeking a cure to managing a problem.

Back to our case study…

Take your mind back to Omar, who has requested a re-referral to ENT for another opinion. He is seeking a cure, but by combining what we know about his symptoms and previous medical investigation, the problem is unlikely be caused by a medical pathology to be fixed, but is a consequence of multiple elements, including the stress of feeling unwell. Therefore, we need to work to reframe his problem and manage it differently.

The challenge is no longer about diagnosis, but explanation, to support health for daily living.

In the following sections we will introduce you to two tools which can help you support patients like Omar in future…

1. The flipped consultation

2. Being a gatekeeper

References

  1. Jones D, Prowse S. Globus pharyngeus: an update for general practice. BJGP. 2015; 65 (639): 554-555. DOI: 10.3399/bjgp15X687193
  2. Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care. Dtsch Arztebl Int. 2015; 112(16):279-87.
  3. Chew-Graham CA, Heyland S, Kingstone T, Shepherd T, Buszewicz M, Burroughs H, Sumathipala A. Medically unexplained symptoms: continuing challenges for primary care. Br J Gen Pract. 2017; 67(656): 106-107. DOI: 10.3399/bjgp17X689473
© University of York/HYMS
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WISDOM - Tomorrow’s Doctor, Today: Supporting Today’s Expert Generalist GP

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